Step back in time for a moment to an NHS with tatty and overcrowded wards, faulty equipment, unappetising food and filthy toilets. Here the nurses are always impossibly busy and the doctors uncommunicative, the temporary staff go unsupervised and the cultural differences of patients are disregarded. Thank goodness the 1970s are over.

In a health service enjoying record levels of spending, and which has undergone numerous management revolutions in the last 30 years, such evils are now a thing of the past - aren't they? Not quite, unfortunately. According to NHS watchdog the Healthcare Commission's annual State of Healthcare report published this week, such demeaning and depressing conditions endure in today's NHS.

And they do so not merely in those long-neglected, fusty corners that have traditionally been the lot of elderly or mentally ill patients. This dreary picture can be found in the very heart of mainstream services - the nation's maternity units that deliver 90% of the 650,000 babies born in the UK every year.

Throughout its report, the commission sticks doggedly to the diplomatic line that "the NHS is improving but still has some way to go", although clearly in many places reality has yet to catch up with the rhetoric of reform. So while the commission does not claim maternity services are universally bad, its chairman, Sir Ian Kennedy, has said "too many pockets of poor practice" exist alongside the centres of excellence.

After three investigations into seriously failing maternity units - and no doubt a welter of anecdotal evidence about others - the commission has now decided with government support that it is time for a full-scale review.

Management, not money, is the root of the problem, Sir Ian suspects. It is easy to see why. In a service galvanised and directed by targets, managers must focus most attention on achieving the minutely specified priorities handed down by the government - or else. Waiting times for admission to hospital and for assessment in casualty have been major areas for management action in the last five years, with notable success. Maternity services have not been high up on most managers' to-do lists until now.

They will not find the problems they encounter there susceptible to a quick fix. Several fault lines that undermine NHS reform - endemic weaknesses in the system - all coincide in maternity units. First is the health service's tendency to neglect anything that is difficult to measure, such as effective communication and establishing good relationships with patients. Sure enough, the commission has found these are significant failings in many maternity units.

Next is the service's heavy reliance on efficient teamworking and its need to break down barriers between healthcare professions - a particular issue in maternity units. Midwifery has for many years battled to assert its status over territory stoutly defended by obstetricians. Such professional power struggles can lead to an uneasy atmosphere if not downright dysfunctional wards, and the commission has found evidence of both.

Women about to give birth usually want to exercise choice over the nature of their care more than most patients. Meeting their wishes can be a challenge for staff, yet the nature of giving birth means the entire patient experience takes on unique importance: people want it to be joyful and memorable in a way that they don't if they are just having their appendix removed. Meanwhile, the costs of medical accidents in obstetrics are among the highest in any branch of medicine, while shortages of midwives are among the most severe of any staff group.

Dynamic leadership is needed to rescue units floundering under these difficulties, Sir Ian says. No one could quibble with that, but it will have to come from more than the much maligned "administrators" at whose door the press and public are always ready to dump all the NHS's shortcomings. They will have their part to play and - no doubt - lost ground to make up like everyone else. But it is clinical leadership that will be needed in maternity services as never before. As the Healthcare Commission's investigations have shown, where disillusioned senior doctors and nurses have ducked this responsibility, the patient is the biggest loser.